Letters: Response to the Letter to the Editor
To the Editor,
Thank you for the opportunity to respond to Sufrin et al.1 We affirm that the historical and current context of coercive practices regarding contraception must be carefully considered when expanding contraceptive access. That was precisely the rationale for our investigation of the experiences of incarcerated women offered education and long-acting reversible contraception through the Tennessee Department of Health program.
In preparing this response, we relistened to all audio-recorded interviews and reread the interview transcripts and field notes. We specifically looked for evidence of the Sufrin et al contention that the program “devalues the reproduction of women with opioid use disorder (OUD)” and that “linking contraception and NAS education could be experienced by individuals as subtle ‘scare tactics’ that they should not be reproducing.”1(pe10) The interview guide contained 11 separate open-ended interview questions (plus probes) to specifically explore the experience of direct or subtle pressure from service providers to use long-acting reversible contraception.
Our reanalysis of the data verified our original conclusion that the program was overwhelmingly valued by the women and experienced as voluntary. Several women interviewed expressed gratitude for the respect with which they were treated, for example, “The nurses were very respectful, very nice. They actually talked to us instead of at us.” These sentiments were unprompted as none of the questions asked about being treated with respect. All respondents who received clinical services stated they would recommend the program to others, and all affirmed that they would return to the same providers for their reproductive health care: “I would absolutely go back in a heartbeat. They're great.”
With regard to combining comprehensive contraception education with education of neonatal abstinence syndrome (NAS), none of the respondents, including the multiple women who reported having had a baby born dependent on opioids, connoted feelings of shame or overt or subtle pressure based on the NAS education. A few women said that more emphasis should have been placed on NAS prevention.
Seventeen of the 18 women reported that they experienced the program as entirely voluntary: “If anything they ask you over and over if this is what you want. I think they asked like 10 times. But each time I felt more reassured. I think it is a good thing.” One woman did report experiencing indirect pressure to use birth control. The pressure occurred in the one-on-one sessions with the nurse practitioner after an education session and was conveyed through “...the way of their voices, like they were more firm, more demanding.... They responded like you're doing the right thing when I chose the method.” When asked about her perceived reason for the pressure, the woman said it was due to her young age. She did not report substance use as the reason for pressure and said regarding the education on NAS: “I actually liked it. It was a lot of education.”
Even one instance of undue pressure to control reproduction is too much. However, the appropriate solution to nonsystemic pressure by individual staff members is continued monitoring and quality improvement, rather than an accusation of eugenics.2 In this instance, the program leadership took appropriate action.
Finally, Sufrin et al claim we overestimated cost savings by assuming no pregnancies end in miscarriage or abortion. In fact, we assumed 46% to 47% of pregnancies to women with OUD end in miscarriage or abortion.
—Clea A. McNeely, DrPH, MA
—Sadie P. Hutson, PhD, RN, WHNP-BC
University of Tennessee, Knoxville
—Tara L. Sturdivant, MD
East Region Tennessee Department of Health
—Jennifer M. Jabson Tree, PhD, MPH
University of Tennessee, Knoxville
—Brittany S. Isabell, MPH
Tennessee Department of Health
1. Sufrin C, Terplan M, Scott C, Roberts S. Expanding contraceptive access for women with substance use disorders: partnerships between public health departments and county jails. J Public Health Manag Pract. 2019;25(6):E10–E11.
2. Hardee K, Harris S, Rodriquez M, et al Achieving the goal of the London Summit on Family Planning by adhering to voluntary, rights-based family planning: what can we learn from past experiences with coercion? Int Perspect Sex Reprod Health. 2014;40(4):206–214.